Professional Liability Claims Examiner III _ Team Leader
- medical terminology
- Excel
Not enough detail in this posting to match
POSITION SUMMARY: Under the oversight of the Area Manager, the Claims Examiner III – Team Leader reports to the Claims Supervisor and/or Area Manager and is responsible for managing all aspects of Professional Liability claims from inception through resolution, within established authority levels and company guidelines.
In addition to maintaining an active caseload, the Team Leader provides day-to-day guidance, technical expertise, and operational support to Claims Examiners to promote consistency, quality, and adherence to established claims-handling practices. This position requires frequent interaction with clients, claimants, TRISTAR management, and internal staff.
The Team Leader may also provide functional oversight, coaching, and mentorship to assigned Claims Examiners while partnering with the Claims Supervisor on escalated claims, training needs, workflow management, and performance-related matters
DUTIES AND RESPONSIBILITIES:
- Provide day-to-day guidance, technical support, and work direction to Claims Examiners assigned to the NVA Team whose responsibilities are similar to those performed by the Team Leader.
- Manage an active caseload of approximately 150–165 Professional Liability claims in accordance with established company and client standards.
- Conduct timely and thorough investigations of assigned claims, including gathering and evaluating relevant documentation, evidence, statements, and other information.
- Review and interpret applicable policies, endorsements, coverage provisions, and relevant laws to determine coverage, liability, damages, and appropriate claim-handling strategies.
- Communicate professionally and effectively with clients, claimants, legal counsel, service providers, vendors, and other involved parties regarding claim status and resolution.
- Establish and maintain accurate reserves within assigned authority and company and client guidelines. The position may have higher authority limits than Claims Examiner I and Claims Examiner II positions.
- Review and approve authority requests submitted by assigned Claims Examiners within delegated authority levels and direct Claims Examiners to obtain additional authority when required.
- Negotiate, settle, and finalize assigned claims within delegated authority levels and obtain additional settlement authority when necessary.
- Maintain an effective diary system, complete timely case reviews, and thoroughly document all claim activity, evaluations, decisions, communications, and action plans.
- Promptly communicate significant claim developments, coverage concerns, litigation issues, exposure changes, and recommended strategies to the Claims Supervisor, Area Manager, and client.
- Conduct independent claim-file reviews to evaluate claim-handling quality, reserve accuracy, documentation, compliance, and adherence to established action plans.
- Work alongside the Supervisor with training, coaching, and mentoring Claims Examiners and provide feedback regarding technical development and work quality.
- Identify and escalate workflow concerns, quality issues, client-service matters, and other operational risks to the Claims Supervisor or Area Manager.
- Comply with all applicable laws, regulations, company policies, client service instructions, and claim-handling procedures.
- Perform other duties as assigned.
EQUIPMENT OPERATED/USED: Computerand other officeequipment.
SPECIAL EQUIPMENT OR CLOTHING: Appropriateoffice attire when on video or attending client meetings.
Qualifications
QUALIFICATIONSREQUIRED:
Education/Experience: Bachelor’s degree in arelated field (preferred); three (3) or more years of related experience; or equivalent combination of education and experience.
Knowledge, Skills, andAbilities:
- Technical knowledge of coverage, statutory regulations, and medicalterminology.
- Analyticalskills.
- Excellent written and verbal communication skills, including ability to convey technical details to claimants, clients, and staff.
- Ability to interact with people at all levels in the businessenvironment.
- Ability to independently and effectively manage very complexclaims.
- Proficient in Word and Excel(preferred).
OtherQualifications:
- Active Independent Adjuster New York StateLicense
Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]
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MENTALANDPHYSICALREQUIREMENTS |
- MENTALEFFORT
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- Reasoningdevelopment:
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Followone-ortwo-stepinstructions,routine,repetitivetask.
Carryoutdetailbutuninvolvedwrittenorverbalinstructions,dealwithafewconcrete variables.
Followwritten,verbal,ordiagrammaticinstructions,severalconcretevariables.
X Solvepracticalproblems;varietyofvariableswithlimitedstandardization;interpretinstructions.
Logicalorscientificthinkingtosolveproblems;severalabstractandconcretevariables.
Widerangeofintellectualandpracticalproblems;comprehendmostobscureconcepts. |
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b. Mathematicaldevelopment:
Simpleadditionalandsubtraction;copyingfigures,counting,andrecording.
Add,subtract,multiply,anddividewholenumbers.
X Arithmeticcalculationsinvolvingfractions,decimals,andpercentages.
Arithmetic,algebraic,andgeometriccalculations.
Advancedmathematicalandstatisticaltechniquessuchascalculus,factoranalysis,andprobability determination.
Highlycomplexmathematicalandstatisticaltechniquessuchascalculus,factoranalysis,andprobability determination requires theoretical application. |
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c. Languagedevelopment:
Abilitytounderstandandfollowverbalordemonstratedinstructions;writeidentifyinginformation; request supplies verbally or in writing.
Ability to file, post, and mail materials; copy data from one record to another; interview to obtainbasicinformationsuchasage,occupation,andnumberofchildren;guidepeopleandprovidebasic direction.
Abilitytotranscribedictation;makeappointmentsandprocessmail;writeformlettersorroutinecorrespondence; interpret written work instructions; interview job applicants.
X Abilitytocomposeoriginalcorrespondence,followtechnicalmanuals,andhaveincreasedcontactwith people.
Abilitytoreport,write,oreditarticlesforpublication;preparedeeds,contracts,orleases,prepareand deliver lectures; interview, counsel, or advise people; evaluate technical data. |
Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount offorcefrequentlyorconstantlytolift,carry,push,pull,orotherwisemoveobjects.Sedentarywork |
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involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
X Lightwork:
(Iftheuseofarmand/orlegcontrolsrequiresexertionofforcesgreaterthanthatforSedentaryWork and the worker sits most of the time, the job is rated for Light Work).
Mediumwork:
Heavywork:
Veryheavywork:
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b. Visualrequirementsnecessarytoperformthejob:
Far vision: clarity of vision at 20 feet ormore
X Near vision: clarity of vision at 20 inches orless
X Mid-rangevision:clarityofvisionatdistancesofmorethan20inchesandlessthan20feet
Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are
Colorvision:abilitytoidentifyanddistinguishcolors
Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point |
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2. PHYSICAL EFFORT(cont.) |
FREQUENCY |
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c. Physicalactivitynecessarytoperformthejobandfrequency(e.g.,continually,frequently, or occasionally):
Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing |
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Balancing:
X Stooping:
X Kneeling:
X Crouching:
Crawling:
X Reaching:
X Standing:
X Walking:
X Pushing:
X Pulling:
Foot Motion:
X Lifting:
X Fingering:
X Grasping: |
requiredexceedsthatrequiredforordinarylocomotion.
Maintainingbodyequilibriumtopreventfallingwhenwalking,standing,or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
Bending body downward and forward by bending spine at the waist.Thisfactorisimportantifitoccurstoaconsiderabledegreeandrequiresfull use of the lower extremities and back muscles.
Bending legs at knee to come to a rest on knee orknees.
Bendingthebodydownwardandforwardbybendinglegsandspine.Moving about on hands and knees or hands and feet. Extendinghand(s)andarm(s)inanydirection.Particularly for sustained periods of time. Movingaboutonfoottoaccomplishtasks,particularlyforlongdistances.
Usingupperextremitiestoppressagainstsomethingwithsteadyforceinorder to thrust forward, downward, or outward.
Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.
Using feet to pushpedals.
Raising objects from a lower to a higher position or moving objectshorizontallyfrompositiontoposition.Thisfactorisimportantifitoccursto a considerable degree and requires substantial use of the upper extremities and back muscles.
Picking,pinching,typing,orotherwiseworkingwithfingersratherthanwith the whole hand or arm as in handling.
Applyingpressuretoanobjectwiththefingersandpalm. |
Occasionally |
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Occasionally Occasionally |
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Occasionally Occasionally Occasionally Occasionally |
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Occasionally |
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Frequently |
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Frequently |
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Occasionally |
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2. PHYSICAL EFFORT(cont.) |
FREQUENCY |
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XTalking: Expressing or exchanging ideas by means of the spoken word. Thoseactivitiesinwhichworkersmustconveydetailedorimportantspokeninstructions to other workers accurately, loudly, or quickly.
XHearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to |
Frequently
Frequently |
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makefinediscriminationsinsound,suchaswhenmakingfindadjustments on machined parts.
Feeling: Perceivingattributesofobjects,suchassize,shape,temperature,ortexture by touching with skin, particularly that of fingertips.
XRepetitive Substantialmovements(motions)ofthewrists,hands, Motion: and/or fingers. |
Frequently |
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3. WORKINGCONDITIONS
Disagreeablejobconditionstowhichtheemployeemaybeexposedandthefrequency(e.g.,continually,frequently, or occasionally) of this exposure. |
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WORKINGCONDITION ENVIRONMENTAL FACTOR |
NATURE/REASONOF EXPOSURE |
FREQUENCY |
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Dirt/Dust |
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Noise |
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Temperatureextremes |
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Dampness |
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Vibrations |
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Equipmentmovementhazard |
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Chemicals/solvents |
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Electricalshock |
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Significantworkpace/pressure |
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Odors/Fumes |
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Other(specify): |
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Professional Liability Claims Examiner III _ Team Leader · Tristar Insurance